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National Transportation Safety Board RI LUBUS a N PUNUM E O T RAN SP T O L R A T National Transportation Safety Board URIB LUS A N PUNUM E O T I I O T Washington, D.C. 20594 A N N S A D FE R TYBOA Safety Recommendation Date: April 11, 2000 In reply refer to: A-00-30 and -31 Honorable Jane Garvey Administrator Federal Aviation Administration Washington, D.C. 20591 In this letter, the National Transportation Safety Board recommends that the Federal Aviation Administration (FAA) take actions to address safety issues concerning the current lack of cockpit imagery and the location of flight recorder circuit breakers. These recommendations were prompted by the lack of valuable cockpit information during the investigations of several aircraft incidents and accidents, including USAir flight 105 on September 8, 1989, ValuJet flight 592 on May 11, 1996, SilkAir flight 185 on December 19, 1997, Swissair flight 111 on September 2, 1998, and EgyptAir flight 990 on October 31, 1999. This letter summarizes the Safety Board’s rationale for issuing the recommendations. In its report on the September 8, 1989, incident involving USAir flight 105, a Boeing 737, at Kansas City, Missouri, the Safety Board cited the need for a video recording of the cockpit environment.1 The report pointed out the limitations of existing flight recorders to fully document the range of the flight crew actions and communications. It also noted that the introduction of aircraft with electronic “glass” cockpits and the use of data link communications would enable the flight crew to make display and data retrieval selections that will be transparent to the cockpit voice recorder (CVR) and digital flight data recorder (DFDR). The Safety Board indicated that it would monitor and evaluate progress in the application of video technology to the cockpits of air transports. In the 9 years since that incident, considerable progress has been made in video and flight recorder technologies, and the need for video recording has become more evident. Electronic image recording of the cockpit environment is now both technologically and economically feasible. On May 11, 1996, the crew of ValuJet flight 592, a DC-9-32, reported smoke and fire shortly after departing Miami, Florida. The flight recorders stopped about 40 to 50 seconds before the airplane crashed on its return to the airport, killing all 111 passengers and crew. The exact smoke and fire conditions that were present in the cockpit during the last few minutes of flight are not known. 1 National Transportation Safety Board. 1990. USAir Flight 105, Boeing 737-200, N283AU, Kansas City International Airport, Missouri, September 8, 1989. Aircraft Incident Report NTSB/AAR-90/04. Washington, DC. 7249 2 On December 19, 1997, SilkAir flight 185, a Boeing 737, entered a rapid descent from 35,000 feet, which ended with a high speed impact in the Sumatran River near Palembang, Indonesia. There were 104 fatalities. The Indonesian investigation, in which the Safety Board participated, determined that both flight recorders stopped prior to the airplane entering the rapid descent. The lack of recorded information concerning the circumstances in the cockpit has continued to hamper the investigation. On September 2, 1998, Swissair flight 111, an MD-11, on a regularly scheduled passenger flight from New York to Geneva, Switzerland, diverted to Halifax after the crew reported smoke in the cockpit; the airplane crashed into the waters near Peggy’s Cove, Nova Scotia, killing all 229 passengers and crew on board. The exact cockpit smoke and fire conditions that led to the crew’s decision to descend from cruise flight and to divert to Halifax is unknown. On October 31, 1999, EgyptAir flight 990, a Boeing 767-366-ER, on a scheduled international flight from New York to Cairo, crashed in the Atlantic Ocean about 60 miles south of Nantucket Island, Massachusetts, killing all 217 passengers and crew. The Safety Board investigators, in close cooperation with Egyptian government officials, are trying to determine the circumstances that caused the aircraft to descend from its cruising altitude and to impact the ocean. The DFDR and CVR yielded some information, but questions still remain as to the exact environment in the cockpit prior to the upset. These accidents are just the most recent in a long history of accident and incident investigations that might have benefited from the capture of a graphic record of the cockpit environment. Reconstructing the events that led to many accidents has been difficult for investigators because of limited data. This lack of information was evident during the ValuJet investigation. Although the conventional CVR and DFDR recorded sounds and relatively comprehensive airplane data at the time of the initial fire, they did not show the cockpit environmental conditions that the flight crew faced during the initial portion of the fire. This information is critical in determining whether the crew had subtle indications of smoke or fire, whether they followed procedures, or whether or not their actions were effective in clearing smoke from the cockpit. If the conditions were known, it might be possible to modify aircraft systems or training programs to assist future crews in recognizing these indications and effecting a safe recovery. The Swissair MD-11 accident was very similar to the ValuJet accident, except the fire is not believed to have progressed as quickly, giving the crew more time to attempt to effect a safe recovery. However, the lack of cockpit imagery has resulted in many unanswered questions about the origin of the fire, the first indications of a fire in the cockpit, the procedures used, and the effectiveness of the procedures in clearing smoke from the cockpit. Questions also remain regarding the progression of the fire, the availability of critical flight instruments, and whether the crew was overcome or debilitated by the smoke and fire during the final minutes of the flight. The Safety Board’s current investigation of the crash of EgyptAir flight 990, a Boeing 767 aircraft, further highlights the need for electronic cockpit imagery on commercial transport aircraft. Even though the aircraft was equipped with a 30-minute CVR and a DFDR that sampled 3 over 150 parameters, the Safety Board is concerned that the full circumstances that led to the descent into the ocean may never be fully understood because of the lack of electronic cockpit imagery. The data appear to indicate that the flight was proceeding normally at about 33,000 feet until the autopilot disconnected. About 8 seconds later, a large nose-down elevator deflection and reduction of power to both engines were recorded, and the airplane began a rapid descent. During this descent, the airplane reached a maximum nose-down pitch angle of about 40º. The last few seconds of the data recorder showed that the pitch attitude of the aircraft rose to about 10º nose down. It also showed an elevator split in the last 15 seconds, during which the No. 1 elevator (left, or captain’s side) was in the nose-up position, while the No. 2 elevator (right, first officer’s side) was in the nose-down position. The maximum split between the elevators during that period was about 7º. In the last second of data, the elevator split appeared to be lessening. DFDR parameters “engine start lever,” both left and right, changed from “run” to “cut-off.” The changes in these and other engine parameters are consistent with both engines shutting down. Also, the speed brake handle moved from the stowed position to the deployed position. The origins of the actions, as well as the circumstances prompting the actions, that resulted in the changes in the aircraft’s controls may never be definitively resolved because of the lack of electronic images of the cockpit. The Safety Board continues to actively gather more information in an attempt to answer the unresolved questions, but the Board does not have any direct evidence of these actions in the cockpit. The international aviation community is aware of the safety benefits of crash-protected video recorders. Agenda item 3 of ICAO’s FLIRECP/22 specifically dealt with the need for standards and recommended practices (SARPs) concerning video recordings. The panel agreed that the use of video recordings in aircraft cockpits would be very useful and noted that EUROCAE3 was developing minimum operational performance specifications (MOPS). The panel agreed that video technology was maturing to the point where specific technical aspects (for example, frame rate, number of cameras, and resolution per frame) must be determined, and that the ongoing work of EUROCAE and ARINC4 should be considered when developing video recorder SARPs. The panel concluded that it was “strongly committed to the introduction of video recordings in an appropriate and agreed format, and that this should form part of the future work of the panel.” EUROCAE Working Group 50 (WG50) began drafting the fundamental needs for video recorders at its February 1999 meeting, which was attended by recorder manufacturers, regulatory authorities, and accident investigators from around the world, including the Safety Board and the FAA. On February 8, 2000, the Safety Board issued Safety Recommendation A- 99-59, which asked the FAA to incorporate EUROCAE’s performance standards for a crash- protected video recording system into a technical standard order (TSO).5 Given that the 2 International Civil Aviation Organization (ICAO), Flight Recorder Panel second meeting (FLIRECP/2), November 1998. 3 European Organization for Civil Aviation Equipment (EUROCAE).
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